Mitigating Risk

"I want to know if I can have a boyfriend because every time I ask my mum she tells me not to. I would also love to learn about safe sex and safe motherhood (14 year old adolescent girl living with HIV, Zambia cited in Mburu et al., 2013).

A review of the global literature on adolescents found that "there is a significant unmet need for information, education, and services for sexual and reproductive health for married and unmarried young people" (Shaw, 2009: 135; Gay et al., 2015). In Sub-Saharan African countries with available data (2014), only 30% of young women and 27% of young men had comprehensive correct knowledge of HIV (United Nations, 2015). In order to change behavior, young people need to know what the risks are and how to protect themselves. And they need this information early enough to make a difference in outcomes. "Young women, who bear an increasing share of HIV infection, must be reached early ideally before their first sexual experience (which is coerced for many girls in high risk settings) and in time to address other factors, for example, school dropout, which put them at risk for acquiring HIV (Bruce et al., 2011: 8). Young women who can stay in school have increased knowledge about HIV; Women with post-primary education are five times more likely than illiterate women to be educated on the topic of HIV and AIDS (UNESCO, 2010).Equitable expansion of schooling for girls may contribute to the reduction of girls' vulnerability to HIV infection (Jukes et al., 2008). In 1996, Botswana reformed secondary school, expanding access to grade 10. A study found that each additional year of secondary schooling caused by this policy change led to an absolute reduction in the cumulative risk of HIV infection of 8.1 percentage points, with effects particularly large for women (De Neve, et al., 2015).Similarly, education subsidies in Kenya were correlated with reduced rates of STIs among young women (Duflo et al., 2015). Increasing girls' access to secondary education could have a large protective benefit in terms of HIV, in addition to other benefits for educated girls.[See also Advancing Education]

For boys, integrating information about voluntary medical male circumcision (VMMC) within child and adolescent programs could increase uptake (Roxby et al., 2014). Focus group discussions with circumcised and uncircumcised boys in South Africa in 2012 and 2013 found that boys who understood that VMMC reduced the risk of HIV acquisition and who also believed that VMMC would improve their sexual desirability and performance stated that this messaging would increase uptake of VMMC (George et al., 2014). [See also Voluntary Medical Male Circumcision]

Misinformation about sex is dangerous and must be corrected. For example, young people (and adults) need to have a realistic understanding of the risks of differing sexual practices so they may avoid the behaviors that may put them at increased risk for HIV. A study of girls in Senegal found that they engaged in anal, oral and manual sex to remain technically virgins for their wedding night, yet provide pleasure both for themselves and their boyfriends (van Eerdewijk, 2009). Anal sex can increase the risk of HIV transmission (Powers et al., 2008), "yet anal sex continues not to be targeted nor even specifically mentioned in most prevention campaigns." (Halperin et al., 2009b: S57). On the other hand, transmission via oralgenital contact is extremely low, with a study of 135 HIV-negative people (110 women and 25 men in Spain) whose only risk to exposure was unprotected orogenital sex with their HIV-positive partner, with 210 person-years of follow-up and 19,000 unprotected orogenital exposures with the HIV-positive partner and no single HIV seroconversion (del Romero et al., 2002). Sexual health information also needs to clear up misperceptions by youth such as that those with HIV and/or TB will be thin (Puoane et al., 2010) and other misinformation that may lead to stigma or discrimination.

Improving Condom Use Among Young People is Essential

If we use condoms, we do not get pregnant; so, we can go to school and prepare our future Adolescent girl in Liberia (cited in Atwood et al., 2011)

Improving condom use among young people is criticaldata show that if condom use is established during adolescence, it is more likely to be sustained in the long-term (Schutt-Aine and Maddaleno, 2003). However, in a third of countries in Africa, fewer than half of all adolescent women reported knowing where to obtain condoms (Woog et al., 2015).

A recent review of condoms in sub-Saharan Africa found that gender-power dynamics continue to constrain the use of condoms by young women, with increased economic resources under the control of young women correlated with increased condom use (Maticka-Tyndale, 2012). The proportion of adolescent women age 15 to 19 who reported having sexual intercourse in the past year has increased in more than half of countries surveyed, with less than 15% reporting current condom use (Kothari et al., 2012). Of girls aged 15 to 24 reporting higher risk sex, 42% reported condom use. Among boys, this was 59% (UNICEF, 2015d). A recent study from 509 Tanzanian youth aged 15 to 24 found that young women were more likely than males to report that they did not use condoms because their partner does not like condoms or did not want to use them (Hattori, 2014). Given the risks faced by young women, adolescent girls and young women deserve a larger share of resources and policy attention than they have been receiving (Bruce et al., 2011: 2). Obtaining a condom is challenging even for adults: in 2013, in sub-Saharan Africa, only eight male condoms were available per year for each sexually active individual (UNAIDS, 2015c). But creating programs specifically optimized and costed for adolescents has yet to be developed (Stover et al., 2014b).

Comprehensive Sex Education Programs Are Effective

The right to effective comprehensive sexuality education is upheld in the Convention on the Rights of the Child (UNESCO, 2013). School-based comprehensive sex education programs are effective ways to reach a large number of (but not all) young people. Despite the fears of some community leaders and parents that sex education will encourage young people to engage in sex, evidence shows that sex education can delay sexual debut, and can increase condom or contraceptive use by sexually active adolescents (UNESCO, 2009a; Mavedzenge et al., 2010a; Kirby, 2001; Coyle et al., 1999; Hubbard et al., 1998, cited in Satcher, 2001; Grunseit, 1997). Sex education programs that address gender and power in sexuality are more effective in preventing HIV acquisition than those that do not (Haberland, 2015). Achieving behavior change is difficult and many interventions achieve only moderate, if statistically significant, resultsthat include behavior change.

A review from UNESCO of studies of 87 sex education studies, including 29 in developing countries, found a number of positive outcomes: delayed initiation of sexual intercourse, decreased number of sexual partners, increased use of condoms and decreased sexual risk taking. Not every intervention resulted in a decreased risk of HIV acquisition. However, no studies showed hastened initiation of sex, no studies showed an increased number of sexual partners, and no studies showed decreased use of condoms. Only one study of the 29 showed increased sexual risk taking, with the remainder of studies showing no harmful effects of sex education (UNESCO, 2009a).

One community randomized trial in rural Tanzania found a significant impact on knowledge and reported attitudes and behavioral outcomes but had no consistent biological outcome as measured by seroconversion to HIV-positive over the three year period (Ross et al., 2007a) and again for a longer period of time between 1999 and 2008 and again during follow-up nine years after program initiation (Doyle et al., 2010a; MEMA Kwa Vijana, 2008a and b). Biological outcomes were not sustained due to a lack of attention to gender norms (Wight et al., 2012). Yet a review of studies that included comprehensive sex and HIV education programs in developing and developed countries found that two-thirds of the studies reported that adolescents who received sex education were significantly more likely than those who did not receive the intervention to have better knowledge and to engage in protective behaviors (Kirby et al., 2007a).

Views on appropriate programs for adolescents vary. However, strong evidence supports comprehensive sex education that includes promotion of delayed sexual initiation, and also information on contraception including condoms so that when they do start having sex, young people will be protected from unwanted outcomes. Evidence from studies around adolescent access to contraception has found that confidentiality is key (Gay et al., 2015) and adolescents avoid services where confidentiality is not guaranteed (WHO, 2015a).

School-based interventions are logistically well suited to educate youth about sexual activity as schools reach large numbers of young people in an environment already equipped to facilitate learning (Fonner et al., 2014).Yet despite extensive evidence on the importance in preventing HIV acquisition, "comprehensive sex education is a long way from being institutionalized in most low and middle-income countries where the HIV epidemic poses a disproportionate burden of scaled-up, sustainable programmes within educational curricula" (UNESCO, 2012d). Yet some countries have been successful: Nigeria approved a policy to integrate sex education into the curriculum of all Nigerian schools. However, the curriculum had to be approved at the state level and states could tailor the curriculum.Yet Nigeria has successfully scaled up, with a sex education curriculum delivered in 34 out of 36 states and institutionalized pre-service training on sex education. Thailand has also increased coverage of sex education, but not with sufficient hours per student to have the most effective impact (UNESCO, 2012d). Colombia has scaled up sex education to 71 out of 94 Education Departments (UNFPA, 2014). Rutgers WFP, in collaboration with the government of Pakistan scaled up rights based sexuality education in 1,188 schools (Svanemyr et al., 2015). Guidance is available from UNESCO on how to implement and scale up comprehensive sex education (UNESCO, 2012d).

Trying to address age appropriate sex education is challenging, especially in countries where students are years behind in school (Haberland and Rogow, 2015). And most sex education curricula do not address non-sexual modes of transmission, such as injecting drug use, despite data showing that injecting drug use can start early in adolescence (UNESCO, 2012c). Yet while the age distribution of the 12.7 million people who inject drugs globally has not been assessed, "evidence suggests that people who inject drugs begin their injecting practicesoften in adolescence" (Krug et al., 2015: para 1). In Ukraine, 12% of the estimated 272,000 people who inject drugs began injecting drug use before age 15 and 72% began when they were under age 18 (Maksymenko and Shebardina, 2015b). In addition, same sex relationships are often omitted from sex education curricula (Kurth et al., 2015). In Brazil, a multicultural human rights approach to sexuality education is being promoted, which analyzes the sexuality rights dynamic for each group and community and analyzes inequality in access to services and power, using the statistics of gender diversity among Brazilian youth (Paiva and Silva, 2015).

Effective Sex and HIV Education Programs Have Key Characteristics

The evidence shows that key characteristics of effective sex education programs involve experts in research on human sexuality; assess the reproductive health needs and behaviors of those young people who get the education programs; specify health goals, types of behavior affecting these goals, the risk and protective factors affecting the types of behavior, and activities that change the risk and protective factors; design activities that are sensitive to community values and consistent with available resources; pilot test the program and obtain on-going feedback; focus on clear goals of HIV prevention; address situations that might lead to unwanted or unprotected intercourse and how to avoid these and how to get out of them; focus on knowledge, values, norms, attitudes and skills; employ participatory teaching methods; provide scientifically accurate information about the risk of unprotected sexual intercourse and the effectiveness of different methods of protection; address perceptions of risk; address personal values and norms; address peer norms; and address skills and self-efficacy (UNESCO, 2009b). These curriculum-based, adult-led efforts that follow specific guidelines have also been referred to as Kirby characteristics (Pettifor et al., 2013: S158) based on the comprehensive work of Doug Kirby, one of the worlds leading experts in the subject. In addition to the above characteristics, discussion of gender norms that can put both male and female adolescents at risk is also critical to successful efforts (Haberland, 2015; Pulerwitz et al., 2006; Barker et al., 2010b; Peacock, 2009).

If school-based sexuality education is to have maximum impact, it must be taught by trained teachers (Todesco and Gay, forthcoming 2016). In Brazil, more than 60% of schools provide HIV prevention activities, with 43% of these schools having trained teachers and 18% of the high schools with HIV prevention activities also distributing condoms. While not necessarily directly attributable to teachers alone, Brazil has had success in increasing condom use, with a 2008 study showing 81% of adolescents in some schools using condoms during sexual intercourse (Bretas et al., 2008).

"None of the girls could ask questions because they said only boys were at risk. This was our sexual education. I was refused by the clinic when I went for HIV testing. They said it was because I was too young and not married. But I know that I am also too young to die of AIDS." --Rachel Judhistari, founder of Indonesian Independent Youth Alliance (UNAIDS, 2011a: 115)

Young people also want sexuality education programs to address issues of importance to them. A review of research conducted in 13 African countries presenting child and adolescent (7 to 19 years old) perspectives on HIV prevention, together with programmatic work by Save the Children Sweden and the Swedish Association for Sexuality Education, found that sexuality education as taught in schools fails to address issues of concern, such as love, relationships, and how to negotiate safe sex, as well as the need for easier access to confidential health services (Thomsen, 2007). Information can be powerful for young people. A study in Kenya found that providing adolescent girls with information on the relative risk of HIV infection with older partners led to a 28% reduction in unprotected sex. Only 29% of girls and 25% of boys knew that older men were more likely to be HIV-positive than adolescent boys (Dupas, 2011).

Effective Sex and HIV Education Programs Are Cost-Effective and Should Be Scaled Up

Sex and HIV education can be cost saving as well as cost-effective. A review of government-implemented sexuality education programs in Nigeria, India and Estonia found that sexuality education programs were a relatively inexpensive way to avert the higher costs of HIV treatment. The cost per student reached in 2009 for the duration of the entire curriculum in US dollars was $6.90 per student in Lagos State in Nigeria; $13.50 per student in the State of Orissa in India; and $32.90 per student in Estonia with national coverage. However, if only budgetary outlays are considered, i.e. the costs in addition to regular expenses on teacher salaries, costs per student reached were only US$0.60 in Nigeria, US$2.50 in India and US$8 in Estonia. The result of the cost-effectiveness study conducted in Estonia estimate that sexuality education averted 1,970 HIV infections between 2000 and 2009, as well as 4,280 unintended pregnancies and 7,240 STIs. The costs of the sexuality education program (US$5.6 million) were compared with the averted treatment costs of HIV infections averted (estimated lifetime treatment cost per person, US$67,825). It was estimated that the sexuality education program could be considered not only cost-effective but cost saving if it had prevented 83 or more HIV infections, a mere 4% of the HIV infections averted (UNESCO, 2011).

Youth need to be reached with sex and HIV education in a variety of venuesin school, out of school, at workin both rural and urban areas. Studies have also explored the use of internet platforms for HIV prevention education that could be more widely utilized (Villegas et al., 2014). Continued efforts are needed to improve quality of the content, teaching and facilitation methods of sex and HIV education and information, along with policies that support access to effective sex and HIV education programs for young people. Some countries have scaled up sexuality education. But more countries need policies concerning adolescents, with increased clarity for different age groups within adolescence (Bruce et al., 2011). In addition, programs are needed which address the structural factors that affect young peoples vulnerability and risks, such as gender norms and violence against women. [See also Strengthening the Enabling Environment]

"Being free and comfortable with your sexuality is sexual health; and you have an enjoyable life without worries and regret, and you live life to the fullest based on your rights" (Young woman living with HIV from Asia and the Pacific responding to how to define her sexual and reproductive rights cited in Athena et al., 2015: 11).

Abstinence-Only Education Has Been Largely Ineffective in Changing Behavior

"Programs promoting abstinence were found to be ineffective at increasing abstinent behavior and were possibly harmful," according to the Cochrane Collaborative Review Group on HIV Infection and AIDS (2004: 4). These conclusions were based on systematic reviews and a meta-analysis of high methodological quality, which met pre-determined criteria of methodological rigor. Sixty reviews met the criteria (Cochrane Collaborative Review Group on HIV Infection and AIDS, 2004). Cochrane reviews are the "gold standard" of study syntheses. Further, a review of 87 sexuality education programs found no strong evidence that abstinence-only programs delay sexual initiation, hasten a return to abstinence, or reduce the number of sexual partners among adolescents (UNESCO, 2009b; Kirby, 2007). However, a study conducted from 2001 to 2004 in the U.S. found that an abstinence-only curriculum (as opposed to an abstinence-only until marriage curriculum) which did not portray sex in a negative light, did not use a moralistic tone and did not disparage the efficacy of condoms did result in a significant delay of sexual debut among adolescents between the ages 12 and 14. Among the group that received abstinence-only education, 20.6% of the participants reported coitus in the previous three months, compared to 29% in the control group. The abstinence-only intervention did not affect condom use (Jemmott III et al., 2010). A recent meta-analysis found a statistically significant association between promoting abstinence messages and increased frequency of sexual interactions (Johnson et al., 2011 cited in Protogerou and Johnson, 2014). A review of the effectiveness of the government of Kenyas HIV curriculum, which stresses abstinence until marriage, found that the program did not reduce STIs in a cohort of 9,500 girls and 9,800 boys over seven years. Students were followed from age 13.4 to 20.5 years of age (Duflo et al., 2015).

Peer Education Can Be Useful As Part of a Larger Effort

Peer education by youth living with HIV can reinforce messages about protective behavior and can be part of a larger intervention. But there is little evidence demonstrating the effectiveness of peer education in preventing HIV among adolescents. A synthesis of studies from 24 peer-evaluated programs 1997 to 2008 for youth in low- and middle-income countries found that peer education did increase condom use, but had no impact on STI rates (Maticka-Tyndale and Barnett, 2010). Peer education in Rwanda did not result in any differences in outcomes for students exposed to peer-led HIV prevention from those who were not exposed (Michielsen et al., 2012). Peer education in South Africa increased knowledge of HIV but did not have a significant impact on behavior (Swartz et al., 2012). Peer education to promote HIV prevention in one study in Zimbabwe with 4,684 students did not result in decrease in HIV prevalence (Cowan et al., 2010). Others have also noted that peer education among youth has not had an impact (Harrison et al., 2010). Many young people prefer to get information from trusted sources such as health care providers or teachers (Biddlecom et al., 2007). It is possible that peers may not always be seen as a "trusted" source. As for evaluating youth programs, it is helpful to evaluate the effectiveness of youth programs by using biomarkers, such as HIV or STI incidence and/or prevalence and pregnancy whenever possible and "not just indicators for knowledge or self-reported behavior" (DeMaria et al., 2009: 485 translated from the original Spanish by Jill Gay). A meta-analysis of peer education programs found that evaluation quality was low, with questions remaining on the nature and degree of youth participation (Villa-Torres and Svanemyr, 2015: S56).

Programs also need to help parents talk to children about sex. There is some evidence that good communication with parents is associated with delayed sexual debut. Studies in Jamaica, Mexico, South Africa, and Uganda found that parents can be an important source of information about sex and that parents themselves want these skills to talk with their children (Hutchinson et al., 2012; Remes et al., 2010; Givudian et al., 1996 cited in Weiss et al., 1996; Abdool Karim et al., 1991 cited in Wojcicki and Malala, 2001; Damalie, 2001). A study in Kenyawith 403 parents of 10 to 12 year old children found that HIV communication was more likely to have occurred if parents had received information to educate their child about sex (Poulsen et al., 2010).

Ultimately, enabling young people to delay their first sexual experience, to negotiate condom use when they do have sex, to be able to refuse sex, and to reduce the number of concurrent sexual partners are critically important in protecting young women from acquiring HIV. Finding new and promising ways to get accurate information to more adolescentsparticularly adolescents who are not in schoolis also important, and youth-friendly technologies such as text messaging and other communication strategies should be further explored.